Sunshine Home Care, Inc.

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included current employee contact information for the agency for 93 patients and 17 employees. Findings: A review of administrative records showed an Emergency Preparedness Communication Plan did not include contact information for two of 17 current employees for the agency. On 07/23/25 at 1:20 p.m., Staff A stated the Emergency Preparedness Communication Plan was not updated to include contact information for all current employees of the agency.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure statistical quality indicator data was utilized in the analysis and reporting of data in the agency’s QAPI program in calendar years 2023, 2024 and 01/01/25 to 03/31/25 for all patients and employees. Findings: A review of administrative QAPI records showed no statistical quality indicator data was utilized in the analysis and reporting of data in the agency’s QAPI Program in calendar years 2023, 2024 and 01/01/25 to 03/31/25. On 07/23/25 at 1:20 p.m., Staff A stated QAPI records didn’t include statistical data for analysis and reporting of QAPI data during calendar years 2023, 2024 and 01/01/25 to 03/31/25.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure performance improvement projects included measurable goals for the agency in calendar years 2023, 2024 and 01/01/25 to 03/31/25 for all patients and employees. Findings: A review of administrative QAPI Program records showed no measurable goals for performance improvement projects for the agency in calendar years 2023, 2024 and 01/01/25 to 03/31/25. On 07/23/25 at 1:20 p.m., Staff A stated the agency’s PIPS did not have measurable goas in calendar years 2023, 2024 and 01/01/25 to 03/31/25.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the agency’s program evaluation, budget authorization and capital expenditures for calendar year 2024 and 01/01/25 to 07/22/25 for all patients and employees. Findings: A review of administrative governing body meeting records showed no governing body oversite of the agency’s program evaluation, budget authorization and capital expenditures for calendar year 2024 and 01/01/25 to 07/22/25. On 07/23/25 at 1:25 p.m., Staff A stated governing body meeting minutes showed no governing body oversite of the agency’s program evaluation, budget authorization and capital expenditures for calendar year 2024 and 01/01/25 to 07/22/25.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure notification to the physician prior to discharge for two (Patients #7 and #9) of nine patients. Findings: Patient #7 A review of the clinical records showed the patient was discharged from the agency on 03/23/25 as the agency was unable to meet the patient’s needs. Documentation showed no communication or coordination of care with the ordering medical provider prior to the date of discharge to notify that the patient was being discharged from home care services. On 07/23/25 at 1:00 p.m., Staff A stated the agency did not communicate with the ordering provider prior to the discharge from the agency. Patient #9 A review of the clinical records showed the patient was discharged from the agency on 02/28/25 for change in the payor source and showed no communication or coordination of care with the ordering medical provider prior to the date of discharge that the patient was being discharged from home care services. On 07/23/25 at 1:08 p.m., Staff A stated the agency did not communicate with the ordering medical provider prior to the discharge date that the patient was being discharged from the agency.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notice was provided prior to discharge from agency services to one (Patient #9) of nine patients. Findings: Patient #9 A review of the clinical record showed no advance notice of discharge was provided to the patient prior to discharge from the agency on 02/28/25 for a change in the payor source. On 07/23/25 at 1:08 p.m., Staff A stated an ABN was not provided to the patient.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure certified home health aide supervisory visits were completed every 14 days for one (Patient #2) of nine patients. Findings: Patient #2 A review of the POC dated 06/13/25 to 08/11/25 showed orders for CHHA visits of two times a week for eight weeks. A review of the clinical record showed CHHA supervisory visits were completed on 06/09/25 and 07/01/25 (23 days). Home health aide visits were conducted on 06/17/25, 06/19/25, 06/23/25 and on 06/24/25. Documentation showed no patient refusal of supervisory visits, no physician notification and no change in orders. On 07/23/25 at 12:47 p.m., Staff A stated a CHHA supervisory visit should have occurred on or before 06/23/25.”